Cortland Acres Health and Rehabilitation

Inspectors wroteBased on family interview, record review, and staff interviews, the facility failed to assess a resident after a fall that led to a recurrence of a left arm fracture requiring surgical intervention. This was discovered during the complaint investigation process. Census: 92 Resident identifier: #102Resident #102An interview with Rehab Manager #96 on 07/16/26 at 11:05AM, she states Resident #102 fell twice in therapy and provided therapy notes from those falls. Record review completed on 07/16/26 revealed the following Physical Therapy (PT) note. The 05/11/26 physical therapy note reads as follows: [Resident #102] lost balance and was supported per Physical Therapist (PT) via gait belt and manual support at left arm briefly. Pt complained of pain in left arm and provided ice in room. Complexities/Barriers Impacting Session: Imbalance, left arm pain; [...]

Inspectors wroteBased on observation and staff interview, the facility failed to provide resident meals at proper serving temperature. This was found to be true on 1 of 1 lunch meals tested. Facility census 90. a) Lunch Meal on A HallOn 03/24/26 at approximately 12:10 PM, the surveyor had a random lunch tray on A hall temperature tested by the Traveling Dietary Manager. The temperature assessment was also witnessed by the facility's Administrator. The food which was tested were mashed potatoes and gravy with steak. Both food temperatures were tested by the Traveling Dietary Manager as 110 degrees Fahrenheit. On 03/24/26 at approximately 12:15 PM, interview with the Traveling Dietary Manager confirmed and verified that the food did not meet the required serving temperature. [...]

Inspectors wroteBased on document review and staff interviews, the facility failed to provide residents with consistent preferences on the facility's readily available menu. This was found to be true on 2 of 2 menus and has the potential to affect more than an limited number of residents currently residing at the facility. Facility census 90.a) On 03/24/26 at approximately 1:05 p.m., the facility's Traveling Dietary Manager was interviewed. The Traveling Dietary Manager was asked to provide a list of readily available items. The list had the following item listed: it has a choice of egg. [...]

Inspectors wroteBased on observation and record review, resident interview the facility failed to ensure that the meals were served timely.

Inspectors wroteBased on observation and staff interview, staff failed to change contaminated gloves after performing perineal care and before touching clean resident gown and linens. This was true for one (1) of one (1) residents observed during perineal care. Resident identifier: # 70. Facility census: 90. Based on observation and staff interview, staff failed to change contaminated gloves after performing perineal care and before touching clean resident gown and linens. This was true for one (1) of one (1) residents observed during perineal care. Resident identifier: # 70. Facility census: 90.

Inspectors wroteBased on observation, record review, resident interview, and staff interview, the facility failed to provide each resident food prpared in the form to meet their individual needs for Resident's #12, #191, #32, #19, #62, #49, #71, #34, #87, and #46. This created an immediate jeopardy situation due to the risk of choking and aspiration. Resident Identifiers: #12, #191, #32, #19, #62, #49, #71, #34, #87, and #46. Facility census: 91.

Inspectors wroteBased on closed record review, policy review, review of facility investigation and staff interview, the facility failed to ensure Resident #89 received Cardiopulmonary resuscitation (CPR) as resident requested and physician ordered when found pulseless, not breathing and skin pale and warm to the touch. The State Agency (SA) found this failure rose to the level of an Immediate Jeopardy This failed practice was true for Resident #89 but had the potential to affect 32 residents who requested CPR and had a physician order for CPR. Resident identifier: #89. Facility Census: 91.

Inspectors wroteBased on observation and record review, the facility failed to ensure a dignified exsistance took place during dining. The staaff did not ask the residents in the dining room if they wanted to wear clothing protectors. The staff served Resident #23 and #68 meals in large vegetable serving bowls. Residents were not served meals together when they were sitting together at the same table. This failure was a random opportunity for discovery and had the potential to affect more than a limited number of resdients. Resident identifiers: #23 and #68. Facility Census: 91.

Inspectors wroteBased on observation and staff interview, the facility failed to provide a clean and home like environment for all residents in the facility. Facility census 91.

Inspectors wrotee) Resident #60 Activities Based upon record review and staff interview, the facility failed to complete a Care Plan personalized for Resident #60's preferred activities. The Care plan stated, ACTIVITIES: the resident prefers to participate in activities such as The sentence in the Care Plan was incomplete. The care plan is not personalized with any resident preferences, or examples. On 03/11/25 at 1:47 PM, an interview with the Director of Nursing (DON) was held, and the Care Plan for Resident #60 was reviewed. When asked about personal preferences for activities for Resident #60, DON responded, Yes, we seem to have a problem with these. (These, referring to Care Plans.) f) Resident #64 A review of Resident #64's comprehensive care plan found the care plan to be void of person-centered activities. [...]

Inspectors wroteBased on resident interview, record review, and staff interview, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This was true for six (6) of 10 residents reviewed for the care area of activities of daily living. Resident identifiers: #12, #45, #16, #58, #40, and #47. Facility census: 91.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Sharp objects were in unlocked rooms accessible to residents. This was a random opportunity for discovery that had the potential to affect more than a limited number of residents. Facility census: 91.

Inspectors wroteBased on observation, record review, staff interview and resident interview, the facility failed to ensure the food served was attractive, palatable and at a safe and appetizing temperature for Residents #21, #23, #33, #66, #85, #17 and #40. This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #21, #23, #33, #66, #17, and #40. Facility Census: 91.

Inspectors wroteBased upon record review, observation, testing, resident interviews and staff interviews, the facility failed to store, and serve food in accordance with professional standards for food service safety. This has the potential to affect all residents currently residing in the facility. Facility census 91.

Inspectors wroteBased on observation, record review and staff interview the facility failed to implement an ongoing infection prevention and control program (IPCP) to prevent, recognize, and control the onset and spread of infection to the extent possible. The practices described below had the potential to affect more than an isolated number of residents. Resident identifiers: #74. Facility census:

Inspectors wroteBased upon record review and staff interview, the facility failed to complete a minimum of 12 (twelve) hours training during 2024 for nurse aides, including training in caring for residents with dementia and Alzheimer's. This was true for four (4) of five (5) Nurse Aide (NA) personnel files reviewed during this recertification survey. Facility census:

Inspectors wroteBased on record review and staff interview the facility failed to revise the resident's person-centered, comprehensive care plan, and ensure that the transfer status was care planned correctly. This was an issue for one (1) of 32 residents whose care plan was reviewed. Resident Identifier: #52 Facility Census:

Inspectors wroteBased on Record Review and Staff Interview, the facility failed to ensure activities were individualized and patient-centered for Residents #40, #19, #191, #32, #12, and #49. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident identifiers: #40, #19, #191, #32, #12, and #49. Facility census: 91.

Inspectors wroteBased on observation, record review and staff interview the facility failed to follow Physicians orders in relation to a peripherally inserted central catheter (PICC) dressing and a Advanced Directive order. Resident identifier: #74 and #89. Facility census: #91 Finding Include: a) Resident #74 On 03/11/25 at 9:16 AM observation of an Intravenous (IV) dressing indicated it was changed on 03/03/25 in the PM. Review of the Physicians order dated 03/03/25 reads Change PICC/Mid Line dressing to Right Upper Extremity (RUE) every evening shift every 7 days for PICC maintenance. This would indicate the dressing should have been changed on 03/10/25 on the evening shift. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to assess and treat pressure ulcers in accordance with professional standards of practice. This was true for one (1) of four (4) residents reviewed for the care area of pressure ulcers. Resident identifier: #4. Facility census: 91.

Inspectors wroteBased on observation, record review, resident interview, and staff interview, the facility failed to provide oxygen services in accordance with accepted standards of care. This was true for one (1) of one (1) residents reviewed for the care area of respiratory care. Resident identifier: #16. Facility census: 91.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure complete and accurate medical records. This was true for one (1) of 31 residents in the long-term care survey sample. Resident identifier: #32. Facility census: 91.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. During the kitchen tour it was discovered debris in the walk-in freezer and the ice machine was not draining properly. This deficient practice had the potential to affect all residents receiving nourishment from the kitchen. Facility census: 85.

Inspectors wroteBased on observation, staff interview and policy review, the facility failed to maintain an infection prevention program to help prevent the development and transmission of communicable diseases and infections when the nurse administrating medications handled the medications with bare hands. This had the potential to affect more than a limited number of residents. Resident identifiers: #14 and #23. Facility census: 85.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. This was true for one (1) of one (1) residents reviewed under the Respiratory Pathway in the annual Long-Term Care Survey Process. The facility failed to document the reason why blood glucose levels were not obtained on two (2) dates for Resident #64. Resident identifier: #64. Facility census: 85.

Inspectors wroteBased on observation, resident interview, family member interview, policy review, and staff interview, the facility failed to ensure that a resident who needed supplemental oxygen was provided such care, consistent with professional standards of practice. The facility failed to change the oxygen tubing for Resident #59. This was true for one (1) of one (1) residents reviewed under the respiratory pathway in the annual Long-Term Care Survey Process. Resident identifier: #59. Facility census: 85.

Inspectors wroteBased on record review, and staff interview, the facility failed to ensure a complete and accurate medical record. The facility failed to ensure the Physician's Orders for Scope of Treatment (POST) form was completed per directions specified by the [NAME] Virginia Center for End-of-Life Care. This was true for one (1) of 21 sample residents reviewed for the Long-Term Care Survey Process. Resident identifier: #60. Facility census: 85.

Inspectors wroteBased on policy review, medical record review and staff interview, the facility failed to ensure the resident's medical record includes documentation for the influenza and pneumococcal vaccines and failed to update their immunization acknowledgement form and provide current vaccine information statement (VIS) sheets for the pneumococcal series. This is true for two (2) of five (5) residents reviewed for the influenza vaccine and three (3) of five (5) reviewed for the pneumonia vaccines. This practice has the potential to affect more than a limited number of residents eligible for the vaccines. Resident identifiers: #44, #12, and #47. Facility census: 69.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure residents were treated in a dignified manner. Resident #5's indwelling urinary catheter bedside urine collection bag did not have a privacy cover to hide the urine. This was a random opportunity for discovery. Resident identifier: #5. Facility census: 69.

Inspectors wroteBased on observation and staff interview, the facility failed to post the most recent state survey results in a place readily accessible to all residents, family members and legal representatives of residents. The recent survey was attached to a chain and unable to be reached from a sitting position. This was a random opportunity for discovery. Facility Census 69 Findings Included: On 03/28/22 at 12:15 PM, observation of the most recent state survey revealed the survey was chained to a column at the nurses station desk. The chain would not allow the survey book to be taken below the desk top level. On 03/28/22 at 12:40 PM, when Receptionist # 13 was asked if a Resident or visitor in a wheelchair would be able to reach the survey book; Receptionist # 13 stated, sometimes the chain gets tangled. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a resident's Physician's Order for Scope of Treatment (POST) form, conveying end-of-life wishes was complete. One (1) of 18 POST forms reviewed during the Long-Term Care Survey Process (LTCSP) was not dated by the professional assisting with completion of the POST form. Resident identifier: #40 Facility census: 69.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. During the kitchen tour it was discovered the drip pan for the stove was dirty from a large amount of grease build up and temperatures were not recorded for two (2) days for the refrigerators and freezers. This deficient practice had the potential to affect a limited number of residents receiving nourishment from the kitchen. Facility census: 69.